BURL'S AIRCRAFT REBUILD, LLC P.O. Box 671487 * Chugiak, Alaska 99567-1487 ~ Phone: (907) 688-3715 * Fax: (907) 688-5031 Order Toll Free in U.S.: 1-877-688-3715 E-Mail: burl@alaska.com

Name:_______________________________________________________________ Company Name:______________________________________________________ Address:_____________________________________________________________ City:___________________State:______Country:_______Zip Code:____________ Phone:_________________Fax:________________E-Mail:_____________________ Make and Model of Aircraft:_____________________________________________

PARTS ORDER FORM

Qty	Part Number	Description	Price
Shipping & Handling Charges All orders will be shipped via USPS Priority Mail unless otherwise specified. ($3.50 per 2 lbs) 3-5 day arrival time. Insurance: $.80 - $1.00 per $100.00 value (US Only)		Subtotal	$
		S & H (see left)	$
		Total:	$

PAYMENT TERMS: U.S. Funds Mastercard:___            Visa___             Certified Check or Money Order Enclosed____

Card Number:_________________________________________________________

Expiration Date:_______________________________________________________

Cardholder Name:_____________________________________________________

Cardholder Signature:__________________________________________________

Please send or fax completed form to the address above.